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Disclaimers

 
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CombinedNSP
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Joined: 13 Dec 2006
Posts: 1406
Location: Cleveland, OH

PostPosted: Dec Sat 16, 2006 12:48 pm    Post subject: Disclaimers Reply with quote

Disclaimers

Following are 6 different questionnaires/disclaimers
These were contributed for the use of all NSP members/distributors

1) THE PROVERBIAL DISCLAIMER (Used originally in a newsletter for essential oils)
Opinions expressed here are those of individual contributors. This publication does not verify or endorse the claims of contributing writers. The information provided herein is for educational purposes only and is not intended as diagnosis, treatment, or prescription of any kind. The decision to use, or not to use, any information is the sole responsibility of the reader.

THE ABOVE DISCLAIMER is made to protect the editor's gluteus maximus from the wrath of pharmaceutical and medical cartels protected by regulatory law. For what it's worth, Essential Oil related therapy predates the American Medical Association and Food and Drug Administration by at least 6,000 years. You decide!

PHARMACEUTICAL dispensed drugs are toxic failures not fit for human consumption. According to JAMA (Journal of the American Medical Association), Prescribed drug-caused deaths rank 4th on the list of causes of death. 1994 statistics show 106,000 people died from unintended drug side-effects. This would be considered criminal by any other civilized standard.

Dr. Julian Whitaker, M.D., Medical Editor for "Health and Healing," estimates 18 million more people have survived toxic side effects from these same drugs prescribed by their doctors...Over 2 million of them were bad enough to be hospitalized in 1994 alone. Chemical Drugs and the so-called "health" system that promotes using them are part of the problem, not the solution.

YOU ARE RESPONSIBLE for your own health, not the AMA, FDA or your physician. If your physician prescribes a drug for "treatment," ask him or her what known side-effects exist. If he or she downplays any risk, ask yourself this question... Is playing Russian roulette with drugs worth risking your life? It can and does happen...106,000 deaths in one year!! -Daniel E. Deane
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2)
Personal Information:
Name:_____________________________________________
Birthdate: (day &month)____________________
Address:_________________________________Home Phone:_______
City/State/Zip______________________________Work Phone:_______
Email Address:______________________________________
Cell#_________________ Fax#_______________
Please List Any Medical Conditions:_________________________________
Have you ever had surgery or an injury to your back or neck?________
If yes, explain_____________________
Have you ever been diagnosed with any heart problems or high blood pressure?_____
If yes, explain. _________
Have you ever been diagnosed with any foot, ankle or leg problems?______
If yes, explain__________________
Have you ever been diagnosed with any ear, nose or throat problems?_______
If yes, explain________________
Any additional information you wish to share?__________________________
Natural Health Ministry Disclaimer:

I, _______________certify that I am not a licensed physician; I DO NOT PRACTICE MEDICINE; I do not diagnose disease or a medical condition; I do not treat disease or a medical condition; and I do not claim a cure for disease or a medical condition. It is my religious belief to minister to the ails and infirmities of the body, mind and spirit as set forth in the Holy Bible and Spirit of Prophecy. This religious belief Includes Natural Health Maintenance such as: Progressive Relaxation, Nutrition, Educational instructions such as ear candling and use of Essential Oils, along with Other Natural Health Remedies as set forth in these teachings. It is my RELIGIOUS BELIEF that these Natural Health Methods AID IN THE RESTORATION of NORMAL BODY FUNCTIONS. I believe in divine healing however, I do not believe that all healing is of a divine nature. I believe that there is a valid place in our lives for both Natural Remedies along with conventional medical treatment. I will ALWAYS defer health concerns to a traditional health care professional. All therapies and information is not intended to directly or indirectly dispense medical advice or to prescribe the use of herbs as a form of treatment for illness. My sole purpose is to educate about the historical, tried and proven uses of herbs, different therapy modalities and provide a reference tool for those who want to use herbs, vitamins and various NATURAL therapies to feed and potentially assist various body systems. The above named Wellness Consultant disclaims any and all liability if the client chooses to use any products or Natural therapies for their own personal use or pleasure. I further certify that any statements made during the course of counseling, consultation or Alternative therapy procedures are NOT intended to be diagnostic or prescriptive for the person participating in the Natural Health Ministry of ___________________. I emphatically and categorically certify that I DO NOT DIAGNOSE, TREAT, OR CLAIM A CURE FOR ANY DISEASE OR A MEDICAL CONDITION.
Client:
I, ____________________________, have read the above certifications and fully understand that I AM NOT IN ANY WAY receiving a medical diagnosis or treatment for any disease or medical condition, and I understand that a cure is NOT CLAIMED for any disease or medical condition. In view of the above certification, I HOLD HARM LESS, ___________ _____ ______ ____________________________________, Wellness Consultant.
Date: ______________________________________
YOUR HEALTH IS YOUR WEALTH - GUARD IT WITH KNOWLEDGE, UNDERSTANDING AND WISDOM

-Cindy Hoffman
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3)
Here's one I got from my Iridology class. I changed it a little:
CLIENT INFORMATION AND STATEMENT
Name: ________________________________________________
Street Address: ____________________________ Phone: _____________
City: _______________________________________ State: ______
Zip:___________ Date of Birth: __________
HEALTH INFORMATION
1. Have you ever had or been diagnosed as having problems with any of the
following:

___ Anemia ___ Arthritis ___ Cancer ___ Liver

___ Diabetes ___ Ulcers ___ Digestion ___ Circulation

___ Heart ___ Kidneys ___ Lungs ___ Stomach

___ Prostate ___ Fainting ___ Bleeding ___ High Blood Pressure

___ Nerves ___ Hypoglycemia ___ PMS ___ Alzheimer's

___ Thyroid ___ Ovaries ___ Asthma ___ Hay Fever

___ Skin ___Throat ___ Epilepsy ___ Hemorrhoids

___ Gall Bladder___Breast ___ Colon ___Constipation

___ Tumors ___ Bladder ___ Spine/Back ___ Parasites

___ Spleen ___ Pancreas ___ Edema ___ Weight

2. Occupation: ____________________________________________
3. Are you allergic to any foods or medications: __________________________
4. Are you pregnant: _______ If so, how many months: _______
Complaints: __________________________
5. Are you under a lot of stress: ____________________________
6. What condition are you presently under a physician's care for:_________________
7. Please list any medications you are taking:____________________________
8. Please tell us how you learned of our service:___________________________
CLIENT STATEMENT
I understand that I am here to learn about nutrition and better health practices and that I will be offered information about food supplements and herbs as a guide to general good health and this is considered a personal ministry and spiritual counseling.
I fully understand that those who counsel me are not medical doctors or practitioners and I am not here for medical diagnostic purposes or treatment procedures. I am not on this visit or any subsequent visit an agent for federal, state, or local agencies or on a mission of entrapment or investigation.
The services performed by _____________or others are at all times restricted to consultation on the subject of nutritional matters intended for the maintenance of the best possible state of nutritional health and do not involve the diagnosing, treatment, or prescribing of remedies for disease.
Signature: _______________________________ Date: ______________
-Chottsie
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4)

I took this info from different ones and put mine together

Client Consultation Questionnaire

NAME __________________________________ AGE _____ Sex______
DATE ________________
ADDRESS:_________________________________________________
CITY _____________________ STATE ___________ ZIP_________ PHONE (DAY) ___________________ (NIGHT)______________________ FAX _____________________ E-MAIL__________________________ HEIGHT __________ WEIGHT ____________ OCCUPATION______________ NAME OF PERSON WHO REFERRED YOU________________________________ What conditions are you taking medication for?_____________________________ PLEASE PLACE AN "X" BY THE QUESTIONS THAT PERTAIN TO YOU!
____ Do you have a diagnosis from the doctor? If so, what_____________________
____ Are you pregnant? If yes, how far along are you?________________________
____ Are you using chemical birth control?
____ Do you have a lot of stress?
____ Are you allergic to any food or medication?
If so, what? _________________________________________________

Alzheimer's__ Colon__ Hypoglycemia__ Prostate__
Allergies__ Constipation__ Indigestion__ Skin__
Anemia__ Cysts__ Kidneys__ Spleen__
Asthma__ Depression__ Liver__ Sleep__
Arthritis__ Diabetes__ Lungs__ Smoking__
Back\Spine__ Diarrhea__ Menopause__ Stomach__
Bladder__ Digestion__ Migraines__ Stress__
Bleeding__ Edema__ Nausea__ Throat__
Blood Pressure__ Fainting__ Nerves__ Thyroid__
Breast__ Fatigue__ Ovaries__ Tumors__
Cancer__ Headaches__ Pancreas__ Ulcers__
Circulation__ Heart__ Parasites__ Weight__
Colds/flu__ Hemorrhoids__ PMS__ Yeast__

Client Statement
I understand that I am here to learn about nutrition and better health practices and that I will be offered information about food supplements and herbs as a guide to general good health and this is considered a personal ministry and spiritual counseling. I fully understand that those who counsel me are not medical doctors or practitioners and I am not here for medical diagnostic purposes or treatment procedures. I am not on this visit or any subsequent visit as an agent for federal, state, or local agencies or on a mission of entrapment or investigation. The services performed by________________ or others are at all times restricted to consultation on the subject of nutritional matters intended for the maintenance of the best possible state of nutritional health and do not involve the diagnosing, treatment or prescribing of remedies for disease.
Date _____________Signature__________________________________
-Tonja Wells
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5)
This is on my New Client Form so as they fill out other info like their age, phone number, etc, they can read and sign this as well.

Please read and sign:
I am seeking information about nutrition and a wholesome diet, food supplements, herbs, and natural therapies. I understand that Leslie Lechner is NOT a licensed medical doctor. I am not seeking a medical diagnosis, treatment or prescription for any illness. -Leslie Lechner
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6)
This is what I put at the bottom of my client information questionnaire:

"I understand that I am here to learn about nutrition and better health practices and that I will be offered information about food supplements and herbs as a guide to general good health and this is considered a personal ministry and spiritual counseling.
I fully understand that those who counsel me are not licensed medical doctors or practitioners and I am not here for medical-diagnostic purposes or treatment procedures. I am not on this visit or any subsequent visit as an agent for federal, state or local agencies or on a mission of entrapment or investigation.
The services performed by (your name) or others are at all times restricted to consultation on the subject of nutritional matters intended for the maintenance of the best possible state of nutritional health and does not involve the diagnosing, treatment or prescribing of remedies for disease."
Of course I have them sign and date it. -Nedra Denison
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